From ancient times to the present, old age has offered mixe blessings. For some, ages has brought prestige, fame and fortune; for ohters, aging has meant uprecedented hardship, indigency, long-term illness, isolation, and institutionalization. Although thes problems have been with us for some time, it is only in recent yars that public attention has focused on the rapid growth of the aging segment of the population and on recurrent problems attendent upon this growth.
-In recent years, the federal government has funded " numerous research projects in gerontology and geriatrics aimed at enhancing our understanding of the, varied social; psychological, economic, physiological, land other forces affecting the aging. A recent report on the use of giant funds under the Older Americans Act proudly claim's supports of 130 different projects addressess to solving problems of aging in Americans soceity." There is no evidence, however, that any of these projects dealt specifically with,minority elderly-some 1/8 million persons nationally who have received - little attention and of whom there- is but a rudimentary understanding California, Mexican Americans comprise percent of the total population but there has been little systematic research dealing directly with the aging sector of this, large group. This paper focuses on this large ignored subpopulation, Los Viejitos (the old ones").
The health care needs and preventive services available and utilized by Older, persons, particularly Mexican Americans in rural California community was examined. The study reported here sought to answer four major questions:
1. What preventive health care services are aviailable and what forms shou;ld be taken by health care progrmas designed to serve the needs of the aging sector?
2. What preventive health care services are available, and what forms should be taken by health care programs designed to serve the needs of the aging?
3. Whats characteristics - of ethnic minority aged persons do policy makers, program planners administrators, and staff -persons consider important in formulating policy or designing and providing services? Furthermore, what are the structural elements of the service-provider system which are considered significant in contributing ,to detracting from, utilization detracting from, utilization of services among this group?
4. In the provision or planning of services, is there recognition of a need for differential or preferential consideration of Mexican American or other minority aged due to economic and race-related morbidity findings?
In attempting to answer these questions and increase understanding of these issues it was decided that the most productive strategy for discovery would take the form of what has been described as the experience survey.1 This research method involves the use of interviews aimed at gathering and synthesizing information, perceptions and impressions, as well as obtaining provocative ideas and useful insights from experienced and informed persons engaged in a particular activity or setting.
"Providers" as defined in this study are those agencies or persons involved in furnishing services to the aging population of Sonoma County, California.* They include but are not limited to those offering social, psychological health, and medical programs, and activities identifying the aged as a specific principle target group. Because there existed no comprehensive central list of such persons or groups from which a sample could be drawn, it was necessary to seek names of informants from a variety of sources. These yielded a list of more than 46 principle providers of whom 22 were contacted.
The informants were representative of providers ranging from individuals responsible for social services programs to community health and hospital-based nurses, social workers, physicians, community outreach workers, senior centers staff, clergymen, and others. They ranged in age from the mid-twenties to late-sixties and included Mexican Americans and other ethnic minorities, although the majority were "Anglo" in their thirties and forties. These providers were in both the public and private sector and, for purposes of analysis, can be grouped into five categories: (1) public agencies, (2) private nonprofit (voluntary) agencies, (3) commercial agencies, (4) government-funded non-public agencies, and (5) independently involved individuals. In general, these respondents saw themselves functioning to:
- Offer needed services aimed at improving the situation of the elderly
- Protect the rights of the aging to quality services
- Enhance their dignity as human beings and enlarge their continued participation in the life of the community.
Data were gathered through partially structured interviews, conducted primarily in the work place of the respondents over a six-week period of time. An interview guide was developed in which the questions were open ended to allow the respondent to express his/her views and the interviewer to pursue selected aspects of the responses. Interview material was supplemented by observations, minutes of meetings of various groups, and by newsletters and other publications of providers. Conclusions reached, however, are predominantly based on the interviews and attempt to reflect the aggregation of viewpoints expressed.
No hypotheses were advanced and the study was not based on a preconceived theoretical framework. The present work must be considered a post hoc qualitative analysis which can form the basis for a more precise investigation and be suggestive of hypotheses to be tested in future research. This stance reflects that proposed by Blumer2 who suggests that the aim of theory is not necessarily to form scientific propositions, to prove or disprove, but to outline and define situations so as to gain a clearer understanding of social phenomena. This approach can provide "sensitizing concepts" and generate a general sense of reference to suggest the direction along which to proceed in order to gain new insights. The study is admittedly preliminary rather than conclusive. It was intended to clarify concepts, establish priorities for future research, as well as to promote interest, concern, and action in evaluating health care and other services provided to the aging. Thus, it is a form of "action research" which attempts through data collection and analysis to obtain clues aimed to enhancing planning, delivery and evaluation of programs, and provide directions for policy and action.
Needs and Problems
The interviews revealed that the elderly in Sonoma County have pervasive and urgent problems and needs. The problem most frequently mentioned as the major concern of the aging was finances. For a substantial number of persons, old age brings a financial crisis which can result in severe hardships. The sources of economic pressure appear to be:
1. A lengthening of the retirement period, with more persons leaving the work force before age 65. With increased longevity, the retirement period becomes easily one-fourth of life and, in many instances, can extend over a quarter century. Even the most prudent financial planning and resource allocation for this period can prove inadequate. 2. The difficulty of living on fixed incomes in a time of high inflation.
3. A large number of older individuals come primarily from farm, blue-collar and self-employed small business occupations where they have earned little to set aside for themselves.
In 1970, the median income of an aged family nationally was 48 percent that of families headed by younger persons. More than one-half of all older single persons living alone or away from relatives had an income of less then §2,000, and one-third had less than $1,500 annually. In Sonoma County, of the nearly 29,000 persons over 65 years of age, 5,855 (21%) had incomes below the poverty line, with the median income for a single person being $1,749 annually-or approximately $146 per month. Among Spanish-Surnamed persons, the 1969 median income was $6,378, yet 20 percent of all the families were below the poverty line, with a mean income of $2,729-a deficit of $1,500. In addition, the aged are poorer in the Spanish-Surname subpopulation than in other aged groups in the community.
Mexican Americans have been characterized by a chronically depressed socioeconomic status, marked by a low educational level, a high degree of functional illiteracy and limited employment opportunities. One Chicano informat viewed the financial problems of the Mexican-American aged as severe, stating:
Due to lifelong poverty, many of our elderly have been unable to save anything for retirement or collect adequate pensions. Because of their low incomes, with menial jobs at the bottom of the labor market-such as domestics and farm laborers- they collect very little from Social Security and require extra assistance... Some "viejitos" don't even qualify for Social Security because of the kinds of jobs they have held.
Retirement benefits such as Social Security and public and private pensions are the most prevalent and important sources of income for the aging. It comprises at least half the income of the majority of couples and nearly two-thirds of the total income for individuals, nationally. Recent increases have brought the average Social Security monthly benefit to approximately $200 for single individuals and $341 for couples. However, despite these increases, benefits have not kept up with the adverse effects of inflation of the past several years. After subtracting housing, food, and medical expenses from the budget, there is almost nothing remaining for any thing else. It's not unusual for retired persons to pay out half of their incomes or more just on rent. Among the Spanish-Speaking population, census data indicates that even for below-poverty-level families the mean gross monthly rent was $96.00. It appears that a large proportion of elderly individuals are left with incomes inadequate for the usual necessities and comforts of life and have difficulty coping with soaring food and fuel prices, rising taxes, and increasingly expensive housing.
Because of such financial difficulties, retirees who are still active and healthy look for jobs to supplement their income. Yet, it is very difficult to find employment. This is apparently related to high local unemployment, generally, and to discrimination in hiring based on the view that "there's something wrong with being old." Wh^le there is no evidence that an individual's efficiency or creativity necessarily decline abruptly upon reaching 65, apparently, too many employers "being old seems to mean hiring the sick, senile and useless." Additionally, disincentives to employment are created by regulations which can result in the loss of benefits for those earning wages.
A second basic necessity that is also a major expense for aging persons is housing. A number of public-subsidized housing units have been constructed in Sonoma County in recent years. These are primarily large apartment complexes. However, only a small minority of the aged community is currently housed in such units. In terras of income support, at least 20 percent of the older population in the county would be eligible, and even more are in need of adequate housing; yet the number of available units is sufficient for less than a quarter of this number. Many aged are forced to live in inadequate housing, in homes badly in need of repair, and in dilapidated apartments with faulty heating, some lacking running water and toilet facilities. Renters are often afraid to complain about hazardous conditions because the absentee landlords will threaten to raise rents or evict them. Physical disability prevents some tenants from performing even simple maintenance tasks for themselves. Moreover, at least 10 percent of the older population need specialized housing environments due to some form of physical impairment. Such housing is not easily available to renters, and existing housing programs have not always been designed with this fact in mind.
Transportation represents a third extremely critical need, the absence of which can create or enhance many problems of daily living. Without adequate transportation, the effective delivery of services is impaired. The activity and travel behavior of older people, especially the large percentage without automobiles, is at considerable variance from patterns among theyounger working population. Land use patterns presume access to a car. The selection of locations for public service facilities is made through a middle-aged, mobile perspective. Many elderly persons do not own cars or cannot afford to drive them due to high insurance premiums or gasoline and other upkeep costs. In order to reduce some of the problems in transportation, informants in the study favored clustering facilities and establishing multiservice centers with satellite intake points and mobile units throughout the county. Various agencies have responded by providing specialized transportation services such as "Dial-a-Ride" minibuses which can offer limited door-to-door service on request.
Another need identified by several informants is legal services. The aging have special technical legal problems such as pensions and other benefits. Some legal services are available at minimal or no cost to low income persons. These are limited, however. One informant reported that poverty lawyers seem to prefer other clients. Racial discrimination issues are apparently more interesting than age discrimination. Also, older clients may be more difficult to deal with due to some memory or hearing problem... Lawyers find it difficult to empathize with and understand the needs of the aged. One agency sees a need for training para-legal personnel, including elderly persons, to assist the aging poor with legal problems such as benefit claims, wills, and consumer problems.
Nutrition is an area of need identified by the majority of providers interviewed. Inadequate diets are seen as a major contributing factor to health problems. Income limitations make it impossible for some persons to purchase adequate nutritious foodstuff, unless the individual can qualify for foodstamps. Malnutrition can occur at any income level; however, psychological conditions such as loneliness, apathy, and confusion contribute to poor eating habits. Physical disabilities can also make shopping and cooking difficult. Additionally, a need is seen for nutrition education programs since many experts feel older persons require alterations in dietary habits, e.g., increasing consumption of complete proteins and lowering the intake of saturated fats and carbohydrates.
A federally funded nutrition program is in operation in Sonoma County under the auspices of a nonpublic sector provider. It is currently serving, through eight dining sites, one low-cost hot meal five days a week to persons over 60. A proposal for state/federal funding of a similar congregate meal program was recently submitted by another agency and denied. It would have been oriented to the lower socioeconomic sector and would focus on minority persons. In order to attract Mexican American, Filipino, Blacks, and other minorities, the agency planned to incorporate ethnic food preferences and alter meal times to account for cultural differences. If funded, the new meal program would have located dining sites in areas having a high proportion of below-poverty-line persons 60 years of age and over-a potential target population of approximately 3,000 persons.
A concern mentioned in many interviews was the need for expansion of home-health-care programs for those over 65 who are either bedfast or housebound (some 15% of the aged, according to an informant, with an additional 10% estimated to have difficulty getting easily about outdoors). These persons presumably require in-house supportive health care services on a regular basis. At a recent "Issues Conference" sponsored by one provider group, such assistance was seen as a priority need by a majority of those attending. In order to remain independent, possibly more than a quarter of the aging population may require some form of home care. Because these services have been limited and difficult to obtain, it has sometimes led to some type of institutional care-an expensive and undesirable situation in the view of most informants. As one respondent put it: "We need to fill the gap in options between independent living and nursing homes or other forms of institutionalization. In 1970 the federal government spent nearly a billion and a half dollars on nursing home care. In contrast, very little is allocated for programs that might help the person remain at home." Nursing and other home health care services have been expanding to meet this need and to assist the individual in remaining at home as an independent functioning person.
A number of informants favor establishing geratric day care centers-an ambulatory setting for older adults who do not require 24-hour institutional care and, yet, due to physical and/or mental impairment are not capable of full-time independent living. Such a facility could provide a variety of individualized medical, nursing, social, educational, nutritional and recreational services to persons who would otherwise be potential candidates for institutional care.
In attempting to respond to the wide range of needs cited by the providers, numerous agencies have formulated programs to provide services to the aging. The proliferation of these services has been accompanied by a number of problematic developments.
Fragmentation of activities with minimal coordination and a loss of overall perspective by the individual agencies is identified as a problem in the delivery of services by a number of informants. The individual needing assistance is confronted by a network of institutions which may seem too formidable to deal with. Agencies may appear complex and unresponsive. However, one agency planner commented that: "Agencies need to define their limits as well as the systematic relationships and gaps between stages available in the various systems. There is some confusion and lack of coordination where the orbits of activity converge."
"Nationally, the rural elderly are the poorest of the aged group, and yet, they receive less and poorer services than the urban aged," concluded one respondent. Not knowing what services they are eligible for or how or where to obtain them creates a major access barrier. Furthermore, the red tape of agencies in the public sector is cited as a significant problem. "The intake procedures are cumbersome, and the forms are difficult to decipher... There is a never-ending stream of confusing documents which, if not filled out properly, can result in disqualification or endless delays."
Another complaint directed to the public agencies by some providers is the complexity of eligibility rules and the tendency to couch procedures in confusing language so that "the agency staff itself has difficulty making sense out of them." These agencies admit that a major constraint on their functions is their typical bureaucratic structure and processes. The process of interpretation of vague and sometimes contradictory rules, for instance, is a central problem for both the client and the agency worker. However, officials in the public sector emphasize that this highly regulated system, with limited flexibility and well-defined spheres of competence and hierarchical responsibilities, eliminates the personal vagaries of workers and, to that extent, contributes to efficient and predictable functioning. They emphasize that this does not necessarily result in impersonal formal relationships between client and staff. However, from the viewpoint of the private agencies, the impersonal judgments become the foundation of depersonalization and rigidity, inhibiting utilization of needed services and resulting in inequities.
According to some informants, the service agency worker (never their own) may manifest a negative conception of the aged, so that the elderly client may find himself in an unfriendly, uncomfortable atmosphere where there is little concern for his comfort and self-respect. The client may often wait around until overworked, harried employees get to him, then to be notified peremptorily about rules and procedures and be subjected to impertinent questioning. Personal records may be demanded which are not easily available to the elderly client. For some, exposure to such interrogations by numerous unfamiliar persons is a trying experience which may result in a disinclination to pursue needed services. The impersonal bureaucratic structure of some, service provider organizations throws the client into a confusing array of personnel with whom he must interact. Privacy and autonomy are deprived, and a passive, dependent, cooperative role is thrust upon him.
Perceptions of Clientele
One issue over which there was marked difference of opinion among the respondents is the extent to which agencies have valid knowledge of Mexican American cultural life styles and needs and attempt to focus sensitively on the problems of minority aging persons. One informant with extensive experience in the public sector expressed the view that "the problems of the minority aged are the same-all aging have the same basic needs... Too much emphasis on this or that group limits our efforts to meet the needs of all the elderly." Others did not see the aged population as an undifferentiated, homogeneous mass. Some felt that "there is a certain degree of insensitivity to ethnicity... the particular characteristics, needs and problems of minority elderly have been either unrecognized or ignored."
Participation by aging Mexican Americans in both public and private services and programs is generally acknowledged to be "limited." Conditions leading to this situation are limited consumer knowledge of available resources and an absence of skills in both gaining access to and being able to traverse a complex system. Indeed, a number of studies have concluded that minority and lower-income people are culturally unable to make use of many services because they lack the experience and/or information required to make use of the system.5-5 "The low-income elderly do not know how to make the bureaucracy work for them," stated an informant. Being largely at the bottom of the socioeconomic scale, aging Mexican Americans are unlikely to have the skills to handle bureaucratic aspects of certain programs.
Mexican-American elderly are sometimes seen as ignorant, unacculturatedand superstitious-unwilling or afraid to ask government agencies for help because of the negative treatment which they may have received in the past. According to some providers holding this point of view, the Mexican-American elderly have undergone multiple negative experiences with service provider organizations, resulting in avoidance behavior, lack of trust and, hence, a disinclination to seek care except in dire need. Another factor cited is the fear of entering humiliating situations where Anglo professionals will dominate the encounter and make decisions that are not explained or understood and which are not to be questioned or disputed. Accepting assistance, for many elderly, irrespective of ethnic background, may be felt as a threat to their sense of independence.
Another frequently mentioned hindrance to service utilization is the language barrier that still exists in many situations, hampering direct communication between client and provider. Since only a small percentage of elderly Mexican Americans speak English, one of the major problems faced in going to an agency is the lack of sufficient, qualified, full-time bilingual/bicultural staff persons. Recognizing this serious barrier, most providers, particularly in the public and government-funded sector, employ some Spanish-speaking staff-primarily in the lower echelon positions.
A number of respondents cited the extended, multigenerational family unit among Mexican Americans as an important factor contributing to the well-being of the elderly and one which substantially explained the reduced use of many services. It is believed that the Chicano aged, because of "their role and status as the older family member, have the emotional and social support needed to maintain a positive self-image and a positive relationship with their environment." Several service providers mentioned the "supportive quality of the Mexican-American family" toward the aged and strongly defended the validity of such normative stereotypes. Others saw such close family relationships as negatively influencing the well-being of the elderly who lack the support to make use of needed services and benefits.
An extensive ethnographic literature exists which has attributed a distinctive family character to Mexican Americans. It can be summed up as portraying the Chicano as contemporary representatives of the folk society, with kinship bonds far stronger and more supportive than are found in the contemporary, urbanized, nuclear, Anglo family unit. It was only among Mexican American respondents themselves that these popular viewpoints were forcefully repudiated as stereotypical myths.
A second prevalent belief concerns the inhibitory function of folk medical beliefs and practices on the acceptance of more orthodox "scientific" medical treatment. It has been suggested that the vast majority of elderly Mexican Americans adhere to these beliefs. Such assumptions, on the part of certain providers, may be more easily understood in the context of a review of the literature on the health care behavior of the Mexican American. It would show that almost all the articles and books available include a prominent discussion of folk medical lore which is emphasized as the primary source of treatment for health problems.
An informant of this study felt that "people living in poverty have gotten used to not having any care. Of course, they are suspicious and afraid to come to the hospital or doctor's office. They have not replaced other sources of help such as the family, neighbors or the Church."
It is generally recognized that cultural and social variations exist in the manner in which persons define health problems, participate in health maintenance programs, and utilize medical and other health services. Classic studies in the sociomedical field have explored the relationships between such variables as education, social class and income, and the use of various health care services.
While the functions of personal predisposition to seek health care appear to be crucial, considerable research has indicated that the failure of a person to seek treatment is also related to barriers in the delivery system itself.6-14 Some respondents emphasized these factors as has been noted in the previous discussion. These respondents are of the opinion that the absence of appropriate utilization of services by lower socioeconomic groups or ethnic minorities is not always deeply culture bound but can be modified, given changes in the organization and provision of services. Rather than emphasizing solely the subjective elements of underutilization they are concerned with the manner in which the system is structured and the way in which the functional characteristics of helping institutions affect the client's orientation and responce. They believe that certain characteristics of provider resources and their services (e.g., geographical proximity, monetary and psychological costs, social distance, etc.), have inevitable consequences on their use.
Discussion and Conclusions
In exploring the provider sector's perceptions of the aging population's needs and the community's responsiveness to them, a number of elements were identified as significant. One of the major problems needing resolution seems to be how to rationalize and organize services so that they are most efficiently distributed and, at the same time, remain responsive to the unique needs of the individual client. There has been a proliferation of services which has been largely fragmented and uncoordinated, accompanied by jurisdictional disputes and agency conflicts over funding, target populations, authority and status, and by the development of conflicting agency cliques in the community. Each agency appears to consider its particular activities and services of singular importance to the aging community, stressing its efficiency, capabilities and achievements, and emphasizing the benefits derived by the community as a whole. There is motivation among the various agencies to invent new functions for themselves. Informants indicated that further expansions of their services would be desirable if more money were made available and saw any curtailment of their services as undesirable.
In the aging field, each organization has a life of its own with minimal coordination of efforts. Furthermore, the forces which generate this life may be quite divorced from the ostensible primary purpose of serving the aged client. Some of these forces appear to be more directed toward the maintenance of power, prestige, and stability of the organization. A significant proportion of the efforts of some providers would seem to be devoted to politics and rivalry and to ensuring the agency's survival and growth as autonomous institutions, rather than aimed at optimal performance of their alleged functions. As in all endeavors, self-serving interests are found on the part of some provider entities which interfere with the provision of optimal services for the elderly. One problem area seems to be that a substantial percentage of the money allocated to the aging goes into program adminstrative costs and overhead, leaving insufficient funds for the actual provision of services. Such costs might be reduced were the various groups, where feasible, to pool their resources and efforts or at least develop cooperative agreements. There is a need for more accountability from the providers receiving state and federal money for their programs; for when it comes down to actual services, the elderly are simply not getting enough.
Maximally effective intervention strategies require accurate assessment of needs, involving adequate data collection, if the real needs of the elderly are to be met and the quality of their life is to be enhanced. Currently, almost all of the information available seems to be gleaned from census reports. Adequate planning has been hampered by the fact that data have been systematically collected to only a very limited degree. Planning should be based on identified problems of the population to be served and objectives should be clearly and explicitly specified before programs are funded or implemented. Moreover, continuous evaluation is necessary to assess impact, efficiency, relevance, and responsiveness of programs. Plans should include measurable impact estimates. Needed is a scientific, objective data-gathering program, including field research, from which a firm foundation can be established for evaluating, administering, and developing services. Unless plans are based on the needs of the population as identified through such investigations, programs serve no one except, perhaps, the professionals such a system employs.
Some programs appear to be based on mythical perceptions, particularly of the ethnic minority aged population. Service providers need to better understand the differing behavioral patterns affecting their utilization of services. Available local studies do not focus very sensitively on these issues. More attention needs to be given to the problems of disparities in access to care and on evaluation of the differences in utilization by ethnic minority groups. Locally, there is but a rudimentary knowledge base of these factors, inhibiting a firm understanding of this population among providers. Probably, what is required is a comprehensive minority health-need study to be conducted by an experienced, predominantly minority, interdisciplinary staff, independent of local service agencies. Presently, in the provision or planning of services, there is no acute recognition of a need for differential or preferential consideration of this population. Unless the aging services system recognizes the subtle, sometimes hidden social forces that intervene between intention and results, it will be frustrated in its attempts and will fail to provide its best services.
The aging population, as a whole, can be thought of as a new minority created by medical, technical, and social changes of the Twentieth Century making possible this longevity for so many. Social attitudes, structures, and institutions are still attempting to adapt themselves to more equitably and effectively accommodate the elderly into the community's political, economic, and social life (as is being attempted with ethnic minorities). To the extent that the society has succeeded, the aging, generally, have the same privileges and resources as others. To the extent that society has failed to integrate this new minority and effectively respond to their diverse needs, the aged-like other minorities-remain underprivileged, ignored, isolated, and abused.
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